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Providing Care to Patients With Medicare Advantage Plans

With more and more Medicare beneficiaries enrolling in Medicare Advantage plans, it’s important to understand how these Advantage plans work for providers. Patients who enroll in Medicare Advantage plans have effectively opted out of Medicare Part B, and their physician care is covered by the private insurer whose plan they’ve joined.

There are Medicare Advantage plans that are HMOs and PPOs, and even some that are “private fee for service plans” (PFFSPs). Since there are only few PFFSPs, and the rules surrounding them are not as clear as the rules for the HMOs and PPOs, we’ll only be discussing HMOs and PPOs here.

If You Are Enrolled as a Medicare Provider

If you are a Medicare provider in the network of the insurer whose Medicare Advantage PPO or HMO the patient belongs to, then you must accept the fee you have contracted for, which may be higher or lower than the Medicare allowed fee you would receive if you saw a fee-for- service patient.

If you are enrolled as a Medicare provider but are not part of the Medicare Advantage plan’s network, you have three choices.

  1. If the patient has a Medicare Advantage plan that does not allow reimbursement for out of network providers, you are not bound by the Medicare fee schedule unless you choose to be.
  2. If the Advantage plan allows its enrollees to go out of network, you can choose to be a “contract provider” and accept the fee the Advantage plan pays, or you can choose to be a “non-contract provider,” and the plan is obligated to pay you what you would have received if the patient were a fee for service Medicare patient.
  3. Even though you are a Medicare provider, you are permitted to see the patient as if she did not have Medicare coverage and charge your usual and customary fee (or whatever fee the two of you agree to). If you choose this third option, you’ll want to have a contract with the patient to ensure that the patient understands that neither Medicare nor Medicare Advantage fees apply to your care, and that the patient is obligated to pay your fee no matter how she is reimbursed by the Advantage plan.

If You Are Not Enrolled as a Medicare Provider

Although you are not permitted to provide care to a fee-for-service Medicare beneficiary unless you are enrolled and can file claims with Medicare as a provider (or have entirely opted out of Medicare), this is not true for beneficiaries who have chosen to receive their Medicare through an Advantage plan. As stated above, these patients have effectively opted to receive their care outside of Medicare, and since claims are not filed with Medicare, you do not have to be on the Medicare books to see them. There is one caveat: If you have been banned from the Medicare program for any reason, you cannot provide care to Medicare beneficiaries even if they are in Medicare Advantage plans.

Since some patients may not understand the terms of their Advantage plans, it is essential that you make it clear how your reimbursement will be determined: whether you will file claims for them with their plan; whether you will accept whatever fee the plan offers with whatever copay is required; or whether you do not wish to have any relationship with their plan and will require them to pay the agreed-upon fee and seek any reimbursement from their Advantage plan on their own. Of course, whatever you choose to do, you must provide patients with the necessary paperwork to file claims on their own.

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